OBJECTIVE: To evaluate the outcomes of percutaneous nephrolithotomy in patients with solitary kidneys.

METHODOLOGY: Between January 2009 and December 2013, 31 patients with renal stones in solitary kidneys were treated with PCNL. All stones were diagnosed using an unenhanced CT scan. The solitary functioning status of the kidney was congenital absence of the contralateral kidney in 7(22%); opposite nephrectomy in 15(48%); and nonfunctional contralateral kidneys in 9(29%) as detected by nuclear scintigraphy. The serum creatinine and hemoglobin were monitored at regular intervals. The stones were classified using the Guy Stone Score while the complications were analyzed using the Clavien-Dindo Grading System. The mean follow-up in months was 21.3±12.26 (4-48).

RESULTS: The male to female ratio is 1.2:1. According to the Guy Stone Score, the stones were Grade 1 in 54.8% (17/31), Grade 2 in 16.1% (5/31), Grade 3 in 6.4% (2/31) and Grade 4 in 22.5% patients, respectively. The stone-free status was determined with a postop CT scan. Complete stone clearance was achieved in 90.3% (28/31) after a single session of PCNL. The mean operative time was 151±36.7(90-230) minutes. According to the Clavien-Dindo Classification, 19 (59.3%) had no complication, 4 (12.9%) had Grade 1 (fever), 7 (29.2%) had Grade 2 (blood transfusion) and 1(3%) had Grade 5 (postoperative hemodialysis, sepsis and death). The rest had stable or improved renal function without postoperative hemodialysis. The mean rise in serum creatinine was 0.67±1.01 (0.1-3.5) mg/dL. Mean drop in hemoglobin was 1.6±0.89(0.5-3.8) gm/dL.

CONCLUSION: PCNL is effective and safe for patients with nephrolithiasis in solitary kidneys. This minimally invasive procedure achieves a high stone clearance rate with acceptably low morbidity and mortality.

: Distal ureteral injury is a rare complication of laparoscopic radical prostatectomy (LRP). The authorsreport such a case which was repaired successfully with an exclusively laparoscopic approach. Theyalso describe the advantages of the flank position when performing this minimally invasive approach. THE CASE: 61-year-old Filipino male, with a PSA of 10 ng/cc, diagnosed with localized prostatecancer undergoes LRP, utilizing a posterior approach to the seminal vesicles. Intraoperatively, alarge intravesical median lobe was noted which was dissected meticulously after the division of thebladder neck. The excision of the 60gm prostate was completed in the conventional manner followedby a urethrovesical anastomosis. Blood loss was minimal with no apparent intraoperative events.Histopathology confirmed prostate cancer, Gleason score (4+3) with negative margins. Postoperatively,he had progressively high pelvic drain output and noticeably a relatively low urethral catheter output.CT urogram done on POD 8 showed a distal left ureteral disruption with intraabdominal extravasation.The authors performed a laparoscopic left ureteroneocystostomy on POD 9. The patient did wellafter the repair. After removing the indwelling catheter on postoperative day 14, he was dischargedin a good clinical condition. The ureteral stent was removed one month after the reimplantation.Follow-up CT urogram showed unobstructed flow through the reimplanted left ureter. Follow-upPSA at this time was 0.01ng/cc. CONCLUSION Ureteral injury following LRP is a devastating complication which may go undiagnosedintraoperatively. Prompt recognition, followed by a timely minimally invasive repair through alaparoscopic approach is needed to correct this problem.

INTRODUCTION: To determine the risk factors contributing to pulmonary complications among patients who undergo upper pole prone percutaneous nephrolithotomy (uPPCNL). This will serve as a guide to urologists who utilize uPPCNL among their patients, so that they may monitor them more closely for these events. METHODS: A retrospective chart review was done on all patients who underwent uPPCNL from January 2015 to December 2017. Patient characteristics (age, gender, BMI, co-morbidity) and stone demographics (Stone size, Guy’s Stone score, laterality, stone location) were summarized as well as intraoperative parameters inclusive of operative time, number of tracts, estimated blood loss, and length of hospital stay. Point biserial correlation and Pearson Chi-square for independent tests were used to identify the independent predictors of pulmonary complications. RESULTS: Nine hundred ninety-two patients underwent uPPCNL during the study period. Fifty-two (5.2%) had pulmonary complications. Sixty-seven pulmonary complications were tallied because some had two complications at one time. The most common was pleural effusion 35(48%), followed by atelectasis in 16(30%), hospital-acquired pneumonia 14(27%) and acute respiratory distress syndrome 2(4%). Forty-one (78.8%) and 11(21.2%) required medical and surgical interventions, respectively. Higher Guy’s stone scores, larger stone size, and longer hospital stay were significant predictors for developing pleural effusion. Patients with higher preoperative serum creatinine and longer hospital stay were significantly associated with surgical management (p < 0.05). CONCLUSION The incidence of pulmonary complications after uPPCNL is low and only a minority need surgical management. When risk factors are present, these patients need to be monitored closely so that a timely intervention may be done to avoid life-threatening consequences.

OBJECTIVE: The primordial principle in living kidney donation is leaving the better functioning kidney (BFK) with the donor. However, when laparoscopic donor nephrectomy (LDN) is utilized, certain conditions may warrant removing the BFK. These include lesser complex vasculature, renal calculi, or left-sidedness. Reported here are the long-term outcomes of removing the BFK among living donors. METHODS: Chart review was done on all donor nephrectomy patients over a five-year period. Patients whose BFK were removed via LDN were identified. Clinical indications, patient demographics, perioperative and postoperative outcomes were summarized. Creatinine and eGFR at one-day, one-month and one-year follow-up were used to determine renal functional outcomes. RESULTS: Between January 2011 to December 2015, 810 donor nephrectomies were performed: 366 (45.2%) and 444 (54.8%) had open donor nephrectomy and LDN, respectively. BFK was removed in 26 (5.8%) in the LDN and none in the open group. Mean age was 28.9+7.5 (18-49), with a male to female ratio of 4:1. The clinical indications were less complex vasculature in 18 (69%), left-sided BFK in 7 (27%) and renal calculi in 1 (3.8%). The mean operative time was 173 +25 (130–272) minutes, with a mean blood loss of 111 +96 (50-200)cc. The mean length of stay was 3.0+0.2 (2.8-4) days. Grade 1 complications were seen in 5 (19%) patients. There was no mortality. The eGFR after 1 year is 79.4+14.1 (54-91) cc/min. CONCLUSION Removing the BFK during LDN does not impact negatively on the safety and renal functional outcomes of living kidney donors.

OBJECTIVE: To describe the outcomes of standard-sized tubeless PCNL (TSPCNL) in terms of clinical efficacy (stone-free rate, operative time and length of hospital stay) and safety (transfusion rate, infection and complications). METHODS: A chart review was done on all patients who underwent standard-sized PCNL from 2017 to 2019. All cases of TSPCNL were identified. The patient and stone demographics were analyzed including intraoperative and postoperative outcomes. Complications were analyzed using the Clavien-Dindo classification. RESULTS: Seventy-nine consecutive cases of prone, single-tract, upper pole access, tubeless PCNL were identified and analyzed. The mean age was 52.74±11.26 with a female to male ratio of 1:1.4. The Guy’s Stone Score showed 12 (15.2%) Grade 1; 23 (29.1%) Grade 2, 11(13. 9%) Grade 3 and 33 (41.8%) Grade 4 renal stones. Mean stone size was 33.7±14.1mm. The stone-free rate was 98.73%. The mean hemoglobin change was 13.6±13.9 g/L. The mean creatinine change was 2.65±23 umol/L. The mean length of hospital stay was 2.46±1.84 days. Twenty-four (30.4%) experienced significant pain, which required analgesics in the form of opioid derivatives. According to the modified Clavien-Dindo classification, 6/79 (7.6%) had Grade 1; 4/79 (5.1%) had Grade 2 and 2/79 (2.5%) had Grade 3 complications. There was no mortality. CONCLUSION The authors’ experience adds to the growing evidence that TSPCNL is a reasonable, efficient and safe approach for large volume nephrolithiasis. Clear indications are needed prior to nephrostomy tube placement after standard-sized PCNL.

Recently, the global endourology scene has witnessed a resurgence of interest in supine PCNL (sPCNL). The number of urologists who are attracted to this “simplified method” of PCNL is growing and its promoters are suggesting to abandon the standard prone approach. Debates on the two positions have become commonplace in endourology scientific meetings. The advocates consistently emphasize that when compared to the prone position, sPCNL has multiple advantages for the surgeon, the anesthesia team and the patient. In spite of these, it is evident that many still favor prone PCNL (pPCNL) because of its time-tested proven efficacy and safety. In fact, up to this present day, majority of PCNLs are still done in the prone position. This review article intends to analyze the “current state of affairs” of the two PCNL positions, describing their advantages and disadvantages. Presently, applying the principles of “what is safe and efficacious in one’s hands” dictates the choice of which technique is utilized to treat a patient. Conversely, it is more clinically sound if this choice was made instead, in consideration of, the interplay of the following factors such as the patient’s clinical demographics, the anatomical features of the renal collecting system, the stone burden and characteristics and ultimately, the physician’s training, skills and experience.
Nephrolithotomy, Percutaneous

A 40-year-old female complains of right flank plain associated with progressive abdominal enlargement. She had stable vital signs and normal renal function. CT urogram revealed bilateral flank masses suggestive of bilateral giant angiomyolipomas. She was counseled on the various treatment options and opted to undergo open surgical excision. She underwent an open clamp-less partial nephrectomy with no intraoperative events. Operative time was 120 minutes and estimated blood loss was 250cc. She was discharged in good clinical condition on postoperative day 4. Final histopathological analysis revealed angiomyolipoma. Genetic testing was positive for mosaic variant of tuberous sclerosis. After a year of follow up, she remains stable and is maintained on everolimus. Open ischemia-free partial nephrectomy may be done safely for giant renal angiomyolipomas. Radical nephrectomy should be reserved for the last option because the presence of contralateral disease may also require surgical excision in the future.

INTRODUCTION: Currently, there are limited studies on laparoscopic radical prostatectomy (LRP) in the country. The authors report the clinical and oncological outcomes of LRP over a 10-year experience in a large volume center in the Philippines. METHODS: This retrospective study included 101 patients treated consecutively with LRP from 2008 to 2017. Patient demographics, preoperative prostate features, perioperative data and complications were summarized to determine surgical outcomes. Histopathological results were analyzed to determine oncological efficacy. RESULTS: The mean age was 64.8-7.1 years (R:46-84), BMI was 25.3±3.0 kg/m2 (R:18.7-34.1), prostate volume was 41.1+21.2g (R:7.9-133) and preoperative PSA was 21.5+19.9 ng/mL (R:2.0-100). Operative time was 276.1+70.0 mins. (R:165-475) and estimated blood loss was 604.7+478.4 mL (R: 100-3700). Five (5%) required conversion to open. Time to oral intake was 1.3+0.7 days (R:1-5). Bowel function returned in 2.0+0.9 days (R: 1-4). The drain was removed after 3.7+1.2 days (R:0-9) in 89 patients while 12 patients were discharged with the surgical drain. The length of stay was 4.5+1.8 days (R: 3-14). Pathologically, 26 (25.7%) had extracapsular extension and 14 (13.8%) had seminal vesicle involvement. Three out of 44 (6.8%) who had pelvic lymphadenectomy had nodal metastasis. Thirty (29.7%) had positive surgical margins, the most common site being the apex (17, 56.6%). Thirty-one (30.6%) had Grade I to III complications. There was no mortality. CONCLUSION Laparoscopic radical prostatectomy continues to be a feasible minimally invasive alternative treatment for localized prostate cancer with an acceptable safety profile and high oncological efficiency.

BACKGROUND: Percutaneous nephrolithotomy (PCNL) is the standard of care for the treatment of renal stones >2cm and staghorn calculi. This minimally invasive procedure however has intraoperative hemorrhage as one of its most dreaded complications. OBJECTIVE: To analyze the rate of hemorrhage and transfusion requirements among patients undergoing either PCNL or open stone surgery (OSS). METHODS: This was a retrospective study conducted at the National Kidney and Transplant Institute Medical Records Department. Data were collected for the period of January 2018 to December 2019. RESULTS: One hundred forty cases were included, 102 patients in the PCNL group and 38 in the OSS. The mean age 50.84±11.89 vs. 50.50±10.09 with male to female ratio of 1.2:1 for PCNL and open surgery, respectively. The most common comorbidity was hypertension (89, 63.6%). As regards stone size, majority had >4 cm stone size (61; 43.9%). In PCNL, there was no significant change noted in the hemoglobin (14.69±13.3 vs 12.03±1.91, p= 0.099) as compared to OSS, where there was significant decline (12.77±2.64 vs. 11.06±2.52; = .000. The number of packed red cell units for transfusion was also significantly higher in OSS compared to PCNL group (.526±.861 vs. 159±.502, p .020.) CONCLUSION In the treatment of staghorn calculi, PCNL incurs less blood loss and lower transfusion requirements compared to open stone surgery.
percutaneous nephrolithotomy ; blood transfusion ; hemorrhage

Management of nephrolithiasis in patients with urinary diversions pose a unique therapeutic challenge for the following reasons: 1) retrograde ureteral access is difficult to perform through a bowel diversion and 2) percutaneous renal access becomes challenging because of inability to do a retrograde pyelogram. For this reason, image-guided access through a combined ultrasound and fluoroscopic guidance are both necessary. This clinical problem becomes even more complicated when dealing with a solitary functioning kidney. Treatment should be precise in order to avoid any complications that may progress to renal failure. Presented here is a 15-year-old male adolescent who had previously undergone a radical cystectomy with an ileal conduit for a rhabdomyosarcoma of the bladder last 2008, and complained of flank pain, fever and foul-smelling urine. Imaging studies showed left obstructive hydronephrosis with ureterolithiasis and nephrolithiasis, and an atrophic contralateral kidney. A preliminary nephrostomy tube drainage was done to recover renal function, followed later by percutaneous endoscopic stone management. Discussed here are the challenges involved in his therapy as well as the advantages of a stepwise approach including the short-term outcomes.
ileal conduit ; pediatric ; solitary kidney